Big Brothers Big Sisters: Enroll a Child Guardian Information Guardian First Name Nombre de Padre/Madre o Guardi·n Legal Guardian Mobile Phone N˙mero del celular de Padre/Madre o Guardi·n Legal Would you prefer emails be sent to you in Spanish? Seleccione por favor Yes NoøPrefiere recibir correo electrÛnico en espaÒol? Guardian Last Name Apellido de Padre/Madre o Guardi·n Legal Guardian Email Correo electrÛnico de Padre/Madre o Guardi·n Legal Child Information Child First Name Nombre del niÒo/a Child Last Name Apellido de niÒo/a Child Date of Birth Fecha de nacimiento del niÒo/a Child's Gender Seleccione por favor Female Male UnspecifiedSexo del niÒo/a Child's Race/Ethnicity (check all that apply) AsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOtherRaza/Etnicidad del niÒo/a (Seleccione todas las que aplican) Guardian's Relationship to Child Seleccione por favor Mother Father Sister Guardian Brother Guardian Stepmother Stepfather Grandmother Grandfather Aunt Uncle Other Relative Foster Parent Godparent Other Non-relativeRelaciÛn con el niÒo/a What school does the child go to? øA que escuela va su niÒo/a? Does the child have any physical, mental, or behavioral challenges? øTiene su niÒo/a alguna condiciÛn mÈdica o mental? øTiene su niÒo/a algun problema de comportamiento en la escuela o en su casa? Does the child see a counselor or therapist? YesNoøVa el niÒo/a terapueta o consejero? Have the child's parent(s) ever been incarcerated? YesNoøTiene su niÒo un padre/guardi·n que ha sido o es encarcelado? Address Child's Street Address DirecciÛn del niÒo/a Apartment/Unit Apartamento Zip Code CÛdigo postal City Ciudad State Seleccione por favor Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin WyomingEstado County Seleccione por favor Butts Cherokee Clayton Cobb Dekalb Douglas Fayette Fulton Gwinnett Henry Paulding RockdaleCondado If you do not see your county listed here, please call our office at (404) 601-7000.Si no vea a su condado aquÌ, por favor llame a nuestra oficina: (404) 601-7143. Do you expect to be moving from this address in the next 12-18 months? øVan a mudarse de esta direcciÛn en los prÛximos 12-18 meses? Additional Information How did you hear about Big Brothers Big Sisters? Seleccione por favor College Partner Community Partner Corporate Partner Faith Organization Foster Home Fraternity/Sorority Housing Authority Legal System Neighbor/Friend Other Advertising Other Big Other Little/Parent Previous Involvement/Self Relative School Social Media Special Event Therapist/Counselor WebsiteøCÛmo oyÛ de Big Brothers Big Sisters? Contact Information
